Exam 4 and Final Flashcards by P H

Symptoms of ADHD

-inattention
-hyperactivity
-impulsivity

How well did you know this?

Not at all

Perfectly

Presentation of ADHD in infancy

-irritability, fidgeting, crying
-difficulty feeding
-short periods of sleep/frequently interrupted sleep

How well did you know this?

Not at all

Perfectly

Presentation of ADHD in preschool kids (3-5)

-excessive motor activity
-intense temper tantrums

How well did you know this?

Not at all

Perfectly

Presentation of ADHD in school aged kids (6-11)

-difficulty academically
-combined inattention and hyperactive/impulsive
-combined oppositional defiant disorder, conduct disorder and aggression

How well did you know this?

Not at all

Perfectly

Presentation of ADHD in adolescents (12-18)

-in attention and impulsivity
-significant functional impairement
-higher rates of delinquency, drug and alcohol use
-speeding/MVA»»in ADHD

How well did you know this?

Not at all

Perfectly

Presentation of ADHD in adults

-inattention
-cognitive deficits
-impatient
-greater risk for unemployment, unstable relationships, hospitalizations, incarceration

How well did you know this?

Not at all

Perfectly

Consequences of not treating someone with ADHD

-delays in language, motor or social development
-low frustration tolerance: irritability and mood lability
-impaired work/school performance
-social rejection in childhood and adolescence
-elevated incidence of interpersonal conflicts
-by early adulthood: increased risk of suicide attempts (due to impulsivity)
-increased prevalence of SUD

How well did you know this?

Not at all

Perfectly

If a pt has a hx of substance abuse, what meds do you use?

-atomoxetine, viloxazine, Guanfacine ER, Clonidine ER, or bupropion

How well did you know this?

Not at all

Perfectly

what tx can you give a pt who has Tourette’s Disorder?

dopamine antagonists or aloha-2 agonist

How well did you know this?

Not at all

Perfectly

what tx can you give a pt who has bipolar disorder and/or severe aggression?

*always treat this first before adding adhd meds
-atypical antipsychotic, lithium or anticonvulsant

How well did you know this?

Not at all

Perfectly

Stimulants facts

-1st line therapy in most cases
–> methylphenidate and amphetamines (amph are more potent:
-block dopamine and NE reuptake
-amphet increase catecholamine release
-inhibit monoamine oxidase
-lack of response to one class does not mean lack of response to another

How well did you know this?

Not at all

Perfectly

Adverse effects of Stimulants

-psychiatric: psychosis/mania, aggression/violent behavior, severe anxiety/anxiety attacks –> dose reduction or cessation of stim and supportive tx
-cardiac: increased HR ~5 BPM, increased BP by ~2-7 mmHg (see a 20% increase risk in ED visits due to this)
-growth: ~1 cm decrease over 1-3 years, ~3 kg weight deficit in 1st year of use

How well did you know this?

Not at all

Perfectly

Stimulants drug interactions

-addictive adverse effects when used in combo with another psychostimulants
-MAOIs should not be used within 14 days
-MPH can increase TCA concentrations
-antacids, PPIs, and H2RAs can increase absorption of MPH IR formulations and reduce release formulations
*antacids decrease excretion of AMP, PPIs can increase rate of absorption of AMP
-acidic agents can lower absorption of AMP
-CYP2D6 inhibitors can increase mixed AMP salt exposure
-concomitant use with alcohol can result in stimulants dumping

How well did you know this?

Not at all

Perfectly

MPH LA pearls

-better for morning symptoms b/c it has a higher immediate release component

How well did you know this?

Not at all

Perfectly

MPH PM pearls

-given at bedtime so starts working by the time the pt wakes up in the morning

How well did you know this?

Not at all

Perfectly

Methylphenidate facts

**preferred product for use in children/adolescents
-time to peak can be delayed by high fat meals
-dosing: titrate weekly until clinical response observed, IR products dosed at least BID (preferred for pts < 16 kg), afternoon IR dose should not be given < 6 hours before bedtime

How well did you know this?

Not at all

Perfectly

Methylphenidate pearls

-ramp effect: behavioral effects are proportional to the rate of MHP absorption into CNS
-tics can occur more often with transdermal patch
-BBW for skin reaction with transdermal patch (chemical leuko

How well did you know this?

Not at all

Perfectly

MPH CD

-30% IR and 70% ER beads
-can open and put on applesauce

How well did you know this?

Not at all

Perfectly

MPH LA

-50% IR and 50% ER beads
-can open and put on applesauce
-best for more severe morning symptoms compared to CD/MLR

How well did you know this?

Not at all

Perfectly

MPH XR suspension

-requires VIGOROUS shaking for at least 10 seconds
-reconstituted and good for 4 months

How well did you know this?

Not at all

Perfectly

MPH OROS

-swallow WHOLE, do not chew or crush
-will see shell in poop
-NOT good for ppl with GI strictures

How well did you know this?

Not at all

Perfectly

MPH MLR

better for rebound afternoon symptoms due to larger ER ratio

How well did you know this?

Not at all

Perfectly

MPH XR-ODT

-17.3 mg Qday- not dose eq. will have to titrate other meds from the start if switching

How well did you know this?

Not at all

Perfectly

MPH PM

-no more than 5% of total drug absorbed in first 10 hours
-administer between 6:30-9:30 pm

How well did you know this?

Not at all

Perfectly

MPH transdermal patch

-dose not eq to oral
-drug active for 3 hours after removal
-apply 2 hours prior to desired onset
-may be worn while swimming and/or bathing
-do not cut patches!

How well did you know this?

Not at all

Perfectly

Dex-MPH XR

-50% IR and 50% ER beads
-peak serum 1.5 and 6.5 hrs after taken
-afternoon symptoms control not as good as OROS

How well did you know this?

Not at all

Perfectly

Jornay PM (methylphenidate ER)

-1st layer: 10 hrs to dissolve
2nd layer dissolves throughout the day, 14 hours to drug peal
-20 mg Qday dose in the EVENING (6:30-9:30pm)
*if bedtime dose missed: skip and resume dosing at next bedtime
-

How well did you know this?

Not at all

Perfectly

Lisdexamfetamine

-amphetamine
-designed for less abuse potential

How well did you know this?

Not at all

Perfectly

Dyanavel XR (amphetamine ER solution)

-2.5 mg/mL (approved for > 6 y/o)
-side effects: epistaxis, upper abdominal pain, allergic rhinitis

How well did you know this?

Not at all

Perfectly

Amphetamine XR-ODT/ER suspension (Adzenys)

-orally disintegrating tablet/liquid suspension
-approved for > 6 y/o
-do not chew, must be dissolved

How well did you know this?

Not at all

Perfectly

Mydayis (mixed single entity amphetamine salts ER)

-> 13 y/o
-onset effect 1-2hrs, peak 16 hrs
**cannot convert mg to mg with other amphetamines
-triple time release beads within capsule to reduce medication wearing off

How well did you know this?

Not at all

Perfectly

Amphetamine facts

-increase the release of DA and NE into the synapse from the pre-synaptic nerve terminal
-enhance release of NE in periphery
-high doses: stimulate serotonin release and acts as serotonin agonist
-high fat meals delay time to peak concentrations

How well did you know this?

Not at all

Perfectly

Amphetamine pearls

**preferred stimulant in adults*
-titrate weekly until clinical response
-IR formulations given at least BID
CIs: not the preferred agent if pt has a hx of cardiovascular disease (HTN, arrhythmias, HF, recent MI)

How well did you know this?

Not at all

Perfectly

Atomoxetine and Viloxazine ER for ADHD

-full benefit may not be seen for 6-8 weeks –> behavior may worsen initially (atomoxetine)
AEs: upset stomach, psych and cardio effects, greater fatigue, sedation and dizziness
**only FDA approved ADHD med with BBW for new-onset suicidality

How well did you know this?

Not at all

Perfectly

Clonidine ER and Guanfacine ER for ADHD

-not as effective as stimulants for mono-therapy
-SEs: sedation/dizziness, hypotension, constipation, heart block
-clonidine commonly added adjunct to stimulants
-ER should not be taken with a high fat meal

How well did you know this?

Not at all

Perfectly

Bupropion: 50-300mg/day for ADHD

-weak dopamine and NE reuptake inhibitor
-found beneficial in adolescents with ADHD and depression
AEs: less appetite suppression and weight loss compared to stimulants, seizures

How well did you know this?

Not at all

Perfectly

TCAs: Imipramine, Desipramine, Nortriptlyine for ADHD

-up to 4 weeks to see max effects
-AEs: sedation/dizziness, constipation, heart block, weight gain, overdose toxicity & rapid heart beat

How well did you know this?

Not at all

Perfectly

Lithium/ valproate or carbamazepine for ADHD

-effective for: aggression, explosive behavior, impulsivity
-childhood-onset bipolar disorder or combined ADHD-bipolar disorder

How well did you know this?

Not at all

Perfectly

Antipsychotics for ADHD

-Chlorpromazine & haloperidol: hyperactivity, impulsivity, neg effects on learning, cog function and can cause EPS
-2nd gen: risperidone, olanzapine, quetiapine, ziprasidone and aripiprazole –> severe aggression and risk of metabolic syndrome

How well did you know this?

Not at all

Perfectly

Mechanisms of Pain

Nocicptive
-Stimulation: bradykinins, K+, prostaglandins, histamine, leukotrienes, serotonin, substance P
-Transmission: a-delta fibers: fast (sharp), localized (myelinated)
-preception
-modulation: endogenous opiate system, NMDA receptors decrease effects of opioids, serotonin, NE, GABA, neurotensin

How well did you know this?

Not at all

Perfectly

Pain mechanisms and Responses of NP

NE and 5-HT neurons appear to provide: major descending modulation, inhibition for transmission of nociceptive information to the rostral levels of the CNS
-Endogenous analgesia center: PAG, noradernergic neurons –> inhibit at spinal cord (clonidine)

How well did you know this?

Not at all

Perfectly

Neuropathic pain

-a clinical description which requires a demonstrable lesion or a disease that satisfies established neurological diagnostic criteria

How well did you know this?

Not at all

Perfectly

Nervous System Damage

-increased nerve cell firing
-decreased inhibition of neuronal activity in central structures, usually due to deafferentation
-intact circuitry at the central level but a gain in response (sensitization) such that normal sensory input is amplified and sustained

How well did you know this?

Not at all

Perfectly

Presentation/Assessment of neuropathic pain

1) Spontaneous transmission: continuous (burning, throbbing, aching, shooting, or intermittent (shooting, stabbing, or electric shock-like)
2) Hyperalgesia: increased pain from a stimulus that normally provokes pain
3) Allodynia: pain due to stimulus that does not normally provoke pain

How well did you know this?

Not at all

Perfectly

TCAs for NP

–> nortrityline, desipramine, amitriptyline, imipramine
Advantages: most data, once daily dosing, concomitant insomnia, depression
Disadvantages: delayed onset, anti-ach, cardiotoxic
Dosing: trail at least 6-8 weeks with 2 weeks ! max dose

How well did you know this?

Not at all

Perfectly

SNRIs/SSRIs for NP

-duloxetine and venlafaxine
advantages: duloxetine FDA approved in PDN, fibromyalgia, concomitant depression and better side effect profile
disadvantages: risk of SS +/- interacting meds, duloxetine CI in hepatic impairment and severe/ESRD
*drizalma Sprinkle: DR caps that you can sprinkle on food

How well did you know this?

Not at all

Perfectly

Milnacipran (Savella)

-FDA approved for fibromyalgia
-well tolerated, can improve fatigue
-BID dosing, HTN

How well did you know this?

Not at all

Perfectly

alpah-2 delta ligands MOA

Modulated hyper-excited neurons
-binds to presynaptic neurons at the alpha2-deltha subunit of voltage-gated calcium channels
-drug binding reduced calcium influx into presynaptic terminals
-decreased calcium influx reduces excessive release of excitatory NTs

How well did you know this?

Not at all

Perfectly

Gabapentin for NP

-low incidence on DIs and ADRS, FDA approved PHN
-mild CNS depression, significant in toxicity
Renal things:
–> crcl > 30-59: 400-1400 mg/day BID
–> >15-29: 200-700 mg/day QD
–> = 15: 100-330 mg/day QD

How well did you know this?

Not at all

Perfectly

Pregabalin for NP

-FDA indicated in PDN, PHN & fibromyalgia
-DEA schedule V- dependency, euphoria, mild CNS depression, significant in toxicity, renal insufficiency

How well did you know this?

Not at all

Perfectly

Tramadol for NP

-Pros: moderate pain, less respiratory depression and abuse potential
*neuropathic pain: inhibits the reuptake of NE and serotonin in the CNS
-Cons: drug interactions, dizziness, GI, constipation and seizure risk

How well did you know this?

Not at all

Perfectly

Tapentadol (Nucynta)

-indication: neuropathic pain associated with diabetic peripheral neuropathy
-DEA schedule II
-1st loading dose, may repeat once 1 hr after 1st dose

How well did you know this?

Not at all

Perfectly

Capsaicin

-depletes and prevents accumulation of substance P in peripheral sensory neurons
-FDA approved
Qutenza 8% topical patch: pretreat with local anesthetic to treatment area, use up to 4 patched per application: patches should be applied for 60 mins and repeated no more frequently then every 3 months as needed

How well did you know this?

Not at all

Perfectly

Lidocaine

Indications: PHN, topical anesthesia (skin, mucous membranes, stomatitis) –> if pt can pinpoint an area of pain
-we love this shit!

How well did you know this?

Not at all

Perfectly

Painful Diabetic Neuropathy

1) damage to peripheral nerves: hyper-excitability, spontaneous impulses within axon & dorsal rot ganglion of these peripheral nerves
2) abnormal electrical connections
3) coupling of sympathetic and afferent neurons and abnormal release of substance P from A fiber
4) persistant nerve stimulation activates NMDA receptors located post synaptically in the dorsal horn

How well did you know this?

Not at all

Perfectly

Painful Diabetic Neuropathy tx

-increase NE & 5HT in synaptic cleft: assumed to inc pain suppression induced by the descending inhibitory pathways
-TCAs, MOAIs, NMDA & sodium channel interference
-SNRIs: duloxetine and venlafaxine
-gabapentin and pregabalin

How well did you know this?

Not at all

Perfectly

Post-herpic neuralgia (PHN)

-reactivation of Varicella-Zoster virus (shingles)
-distribution along dermatomes, ofetn causes PHN d/t sensory nerve damage = reduced neurite densities

How well did you know this?

Not at all

Perfectly

PHN treatment

-TCAs
-gabapentin (Gralise ER & Enacarbil), pregabalin
-divaloproex Na
-tramadol
-opioids (oxycontin)
-lidocaine (FDA approved)
-capsaicin

How well did you know this?

Not at all

Perfectly

Low Back Pain

-5th most common office visit reaons
-lumbosacral radiculopathy: most common
-inc pain = fear of movement

How well did you know this?

Not at all

Perfectly

Management of low back pain

-APAP and NSAIDs 1st line for acute pain
-signs or symptoms of radiculopathy or spinal stenosis: consider referral for consideration of surgery or other invasive procedures
(acetaminophen can be used but does not have an anti inflammatory component)

How well did you know this?

Not at all

Perfectly

Fibromyalgia

-enhanced sensitivity to stimuli: heat and cold
-pain is described as a constant dull ache in all 4 quadrants of the body
-often accompanied with fatigue and sleep disturbances and other comorbidities (fog)

How well did you know this?

Not at all

Perfectly

Proposed causes of fibromyalgia

1) abnormalities in the neuroendocrine system, autonomic nervous system
2) genetic risk factors, associated with affective disorders
3) environmental triggers, physical, psychosocial stressors
4) central sensitization: blunted inhibitory response of the descending pain pathway & amplification of pain in the spinal cord spontaneous nerve activity

How well did you know this?

Not at all

Perfectly

Fibromyalgia criteria

pt must satisfy at least 3:
1- widespread pain index >7 and symptoms severity scale score > 5 OR WPI of 4-6 and SSS score > 9
2- generalized pain, defined as pain in at least 4 of 5 regions, must be present. Jaw, chest and abdominal pain are not included
3- symptoms have been generally present for at least 3 months
4- a diagnosis of fibromyalgia is valid irrespective of other diagnosis. A diagnosis of fibromyalgia does not exclude the presence of other clinically important illnesses.

How well did you know this?

Not at all

Perfectly

Fibromyalgia Treatment

-amitriptyline (at low dose)
-duloxetine
-milnacipran (useful in relieving the fog)
-tramadol
-pregabalin
-cyclobenzaprine

How well did you know this?

Not at all

Perfectly

Katie is is taking 20mg QAM of lisdexamfetamine and has been successfully managed for the last 16 months. She cannot fall asleep at night. What is the best option?

Add Clonidine 0.1mg QHS {She is managed, no need to change}

How well did you know this?

Not at all

Perfectly

Justin is a 13 yr old boy who recently started treating ADHD with 20 mg of amphetamine salts ER. His parents state that they feel there is more room for improvements. Which of the following would be the best recommendation?
○ Add cognitive behavioral therapy
○ Switch to methylphenidate 10mg
○ Add afternoon dose of lisdexamfetamine
○ Switch to atomoxetine

Add cognitive behavioral therapy {Pharmacological + Non-Pharmacological}

How well did you know this?

Not at all

Perfectly

Gary is a 28 year old male with psychiatric disturbances and has been given the diagnosis of bipolar. He is having difficulty focusing, sitting still, and is unable to finish projects at work due to his racing thoughts. What is the best initial pharmacotherapy for him?
○ Atomoxetine
○ Valproic Acid
○ Methylphenidate
○ Guanfacine

Valproic Acid {Yes because bipolar is primary so you need to try that first}
-also only 1 environment- need 2

How well did you know this?

Not at all

Perfectly

hich of the following statements is true regarding atomoxetine?
○ In head to head trials it was found to be less efficacious than stimulants
○ It is the only FDA approved ADHD medication with a BBW an increased risk of suicide
○ An adequate trial of therapy to determine efficacy is 4 weeks
○ Three times a day dosing can be used to improve tolerability

It is the only FDA approved ADHD medication with a BBW an increased risk of suicide

How well did you know this?

Not at all

Perfectly

Addison is a 14 year old female with a recent diagnosis of ADHD who was trialed on dexmethylphenidate ER 10 mg QAM who was responding well during the school day but losing focus in the afternoon. Her past medical history includes asthma, ventricular septal defect, and tonsillectomy. What do you recommend? {Heart Defects = all stimulants caution sudden heart death}
○ Add dexmethylphenidate 5mg in the PM
○ Switch to amphetamine salts
○ Switch to guanfacine
○ Switch to atomoxetine

Add dexmethylphenidate 5mg in the PM

How well did you know this?

Not at all

Perfectly

Ianisa 4 year old boy diagnosed with ADHD. The patient has exhausted all non-pharmacological interventions. They decided to initiate a pharmacological treatment at this time. What do you recommend?

Mixed amphetamine salts IR {Approved > 3 years}

How well did you know this?

Not at all

Perfectly

Charlette is a 28 year old female with a longstanding history of SUD, She recently completed a 28 day
inpatient rehabilitation program and has been diagnosed with ADHD. She attends AN weekly. She was previously diagnosed with ADHD and has previously document success with stimulants in the past. She is re-enrolled in college and has already noted difficulty staying focused in class and completing her homework. What is least appropriate option for this patient?
○ Atomoxetine QHS
○ Methylphenidate OROS QD
○ Lisdexamfetamine QD
○ Methylphenidate IR BID

○ Methylphenidate IR BID {High Abuse potential}

How well did you know this?

Not at all

Perfectly

SR is recently diagnosed with hypertriglyceridemia. His psychiatrist would like to prescribe a medication
that will not worsen his metabolic condition (i.e. hypertriglyceridemia). Which antipsychotic would most
likely contribute to the patient’s metabolic syndrome?
○ Chlorpromazine
○ Quetiapine
○ aripiprazole
○ thioridazine

Quetiapine

How well did you know this?

Not at all

Perfectly

RR’s Prescriber is worried about side effects that can be caused of the dose or escalations in dose for the
agent he prescribes. He specifically asks about clozapine. What side effect is NOT associated with dose escalation of clozapine?
○ Seizure
○ Increased risk of agranulocytosis
○ Sedation
○ Respiratory Depression

Increased risk of agranulocytosis {Not dose related}

Despite your excellent recommendation CC’s psychiatrist initiates a regiment of Symbyax
(olanzapine/fluoxetine) however after a few months after taking the highest recommended dose
of olanzapine with fluoxetine, CC is still not seeing a complete resolution of symptoms. What
would you consider CC’s psychiatrist try relative to CC’s regiment.
○ The suboptimal results may be responsible by induced hepatic metabolism
○ This is a Drug-Drug interaction
○ empty stomach
○ wrong time of day

The suboptimal results may be responsible by induced hepatic metabolism {induced
hepatic metabolism due to smoking with olanzapine, not the nicotine but the inhaled
hydrocarbon}

TS has had a significant reduction in his bipolar symptoms since starting his new medication
regiment months ago. According to his medication record, he has recently reported easy bruising
and bleeding and the ER physicians asks you to identify the most commonly associated
medication.
○ Divalproex
○ olanzapine
○ lithium

Divalproex {responsible for thrombocytopenia, decrease counts}

Patient has GI bleed, which drug most likely contributed to it?

SSRI (sertraline) {SSRIs have receptors on platelets so they can contribute to bleeding but they
most likely would not cause a GI bleed}

Patient was on Clorazepate (needs acidic stomach) and the patient is also on tums. What do you
recommend to make the benzo work faster?

seperate from tums

Patient had Panic disorder and wants to start a family. What is the optimal treatment?
○ Valium
○ Paxil
○ Prozac

Prozac

Patient only has money for one prescription this month. What should she pick up?
○ Fluoxetine
○ Naproxen
○ Clorazepate

Fluoxetine {This is not the answer because it has a very long half life and d/c benzos is more
detrimental}

○ Clorazepate{Definitely do not want to d/c abruptly because pt would be at an increased risk of
seizures}

Patient has SAD and is treated with Sertraline, she comes back to the pharmacy and says she still feels like she is being scrutinized. What should we do?
○ Add Prosom
○ Add Klonopin
○ Add Zolpidem

Add Klonopin {Yes add Benzo because SSRIs take 8-12 weeks to work in SAD and Klonopin will
work pretty quick

26 yr old who is an alcoholic and is hospitalized for detox. He had seizures as a child and 2 seizures during
detox. He is on montelukast, miralax and Percocet. What should we give?
○ Disulfiram
○ Naltrexone
○ Diazepam
○ Acamprosate

Acamproste

Question about Delirium Tremens and what is true? Choose all that apply
○ Increased mortality in COPD
○ 5% of patients who have withdrawal
○ onset of 48-96 hours
○ lasts 5 days
○ hallucinations, diaphoresis, and renal failure

○ Increased mortality in COPD
○ 5% of patients who have withdrawal
○ onset of 48-96 hours
○ lasts 5 days

Which of the following can cause a breathalyzer to overestimate/falsely elevate someone’s BAC? (repeat)
Choose all that apply
○ DKA
○ Periodontal Disease
○ High Concentration liquor
○ Disulfiram
○ GERD

DKA
Periodontal disease
Disulfiram
GERD

27 year old really drunk with friends.. described him as beyond sloppy, threw up.. needed
assistance walking, n/v. What level BAC is he approximately at?
○ 0.10
○ 0.15
○ 0.20
○ 0.25
○ 0.35

0.25

MASTtestquestions.Chooseallthatapply
○ Do you prefer distilled spirits, beer or wine?
○ Have you ever lost friends or your job because of drinking?
○ Have you ever gotten in a fight because you were drinking?
○ Have you ever gone to anyone for help about your drinking?
○ Have you ever been hospitalized because of drinking?

○ Have you ever lost friends or your job because of drinking?
○ Have you ever gotten in a fight because you were drinking?
○ Have you ever gone to anyone for help about your drinking?
○ Have you ever been hospitalized because of drinking?

45yearoldmalewithaPMHofobesity,hypertensionandsleepapnea(heusesaCPAP)comesintoyour pharmacy with a prescription for Penicillin G and Lortab. He tells you he recently had a tooth surgery for an impacted, infected wisdom tooth and comes in with prescriptions are for post surgery care. Which of the following two statements are true? Choose all that apply
○ You should fill both prescriptions because his surgery is real and it’s an infection
○ You should check his blood pressure
○ You should not fill Lortab

○ You should check his blood pressure
○ You should not fill Lortab

What is the safest treatment for an 82 year old with Herpes Zoster (PHN)?
○ Capsaicin
○ Lidocaine
○ Gabapentin
○ Nortriptyline
○ Duloxetine

lidocaine

The same patient goes and sees her doctor. She comes up to your pharmacy counter with a prescription for Gabapentin 300 mg TID. SCr=1.2 {She has renal impairment .. CrCl = 23-27 ml/min}. What is the best course of action for this patient?
○ Counsel and dispense to patient
○ Don’t dispense because it is inappropriate
○ Call MD and increase dose to 1800 mg QD
○ Call MD and switch to 300 mg QD
○ Call MD and switch to 100mg QHS

○ Call MD and switch to 300 mg QD

Patient is on Duloxetine and has seen an improvement in pain but still has some. What is the next step?
○ Start an opioid
Start an SSRI
○ Start a TCA
○ Add Gabapentin or Pregabalin
○ Add SNRI

Add Gabapentin or Pregabalin {alpha-2 calcium channel modulator}

Which of the following drugs for neuropathic pain require initial dose adjustments for impaired renal
function? Choose all that apply
○ Amitriptyline
○ Pregabalin
○ Gabapentin
○ Imipramine
○ Capsaicin

○ Pregabalin
○ Gabapentin

*amitriptyline is hepatic only

What is the mechanism of action of Milnacipran most like that helps with fatigue?

Preferential NE reuptake {3:1 NE:5HT}

A 17year old 70 kg high school player is checked from behind and sustains a grade 3 concussion. Within 5
minutes of her regaining consciousness she experiences a generalized tonic clonic seizure. An MRI showed a subdural hematoma. EKG showed skipey wave formation. The patient is hospitalized again for a second generalized tonic clonic seizure. MRI shows no change of the hematoma and is started on Topamax 300 mg daily in three divided doses or 100 mg TID. She reports feeling lethargic and confused after coming 2 weeks later. What is the most likely explanation and the best course of action?

○ Topiramate is most likely causing hepatic encephalopathy and should be discontinued.
○ This is most likely a dose dependent side effect and the topiramate dose should be reduced
to 50 mg BID
○ Hockey players are lethargic and confused in general, so this is not a change from the patient’s
baseline
○ Topiramate is the most likely cause of kidney stones and uremic encephalopathy and should be
discontinued immediately
○ This is most likely a dose side effect and should be changed to 150 mg TID

This is most likely a dose dependent side effect and the topiramate dose should be reduced
to 50 mg BID {start at too much too fast, have intoxicating effect}

Patient comes in the pharmacy for a refill on his lamotrigine. While at the pharmacy, he loses consciousness and falls to the floor, and exhibits severe tonus and stops breathing. After 1 minute he continues convulsing. Generalized convulsions continue for 3 minutes, incontinent of bowel and bladder, with blood coming from his mouth. Within 5 minutes, he resumes consciousness and seems confused and fatigued. 3 minutes later he loses consciousness again and and begin convulsing. What should you do? Choose all that apply
○ Place something soft under his head
○ Loosen tight clothing
○ Turn patient on side so he doesn’t choke on his own spit
○ Stay with patient for entirety of seizure episodes
○ Call 911

Place something soft under his head
○ Loosen tight clothing
○ Turn patient on side so he doesn’t choke on his own spit
○ Stay with patient for entirety of seizure episodes
○ Call 911

Which of the following are important elements of a pharmacist to ask during patient history/intervention
for someone who has epilepsy?
○ How often do you have seizures?
○ What anticonvulsant medications have you used in the past?
○ What medications are you currently taking?
○ Do you notice if you have any emotional triggers?
○ Be sure that patient understands the goal of therapy
○ Ask about pseudo vs. real seizures {wasn’t on 2016 exam}

How often do you have seizures?
○ What anticonvulsant medications have you used in the past?
○ What medications are you currently taking?
Be sure that patient understands the goal of therapy

25 year old with a 5 year history of epilepsy. Patient has abrupt onset of vacant stares, purposeless
movement of arms and hands, guttural utterances, and lip smacking. After 3-5 minutes the patient resumes
normal activities. He has no recollection of the moments when he was having his seizure. How would you classify this type of seizure?
○ generalized absence seizure
○ simple partial seizure
○ complex partial seizure
○ generalized tonic clonic seizure
○ generalized complex seizure

complex partial seizure

Molly is a 21 year old woman with a 1 year history of seizures. Her seizures started 6 months after a motor
vehicle accident with a intracerebral bleed. Patient above has 1-2 seizures per week despite multiple trials
of single anti-seizure medications. Physician wants to start 2 anticonvulsants. What is important to
consider? Choose all that apply

○ The second agent should be for a seizure type different than the first agent
○ 2 anticonvulsants specific for simple-complex seizures should be tried
○ The second agent should have a different mechanism of action than the first
○ The doses of each agent should ba half of their maximum doses
○ Drugs with similar toxicities should not be used together

-The second agent should have a different mechanism of action than the first

-Drugs with similar toxicities should not be used together

P is a 25 year old female of northern European descent presenting with of worsening of a pre existing
walking and fatigue. She also has new onset of poor bladder control. Which of the following would be used
to treat her acute exacerbation of MS?

Methylprednisolone (Solu Medrol) {Use if good venous access, only use if >48 hours and no fever}

JP is currently on contraception and you are concerned about her becoming pregnant while on MS therapy. Which of the following would be least appropriate (i.e. pregnancy category X) in this patient?
○ mitoxantrone (novantrone)
○ glatiramer acetate (copaxone)
○ fingolimod (gilenya
○ interferon beta 1 a (avonex)
○ teriflunomide (aubagio)

teriflunomide (aubagio) {Category X}

You decide to be cautious and initiate JP on a MS medication that has the least likely possibility of fetal harm in case she does become pregnant. Which of the following poses the LEAST risk of fetal harm?
○ teriflunomide (aubagio)
○ glatiramer acetate (copaxone)
○ mitoxantrone (novantrone)
○ interferon beta 1 a (avonex)
○ fingolimod (gilenya)

glatiramer acetate (copaxone) {Category B}

JPultimatelyhasmorethan2relapsesandwillbegindiseasemodifyingtreatmentforherMSgivenIV
infusion every 4 weeks. Which of the following medications is she now receiving?

Tysabri

JP asks about medical marijuana has the best evidence for helping with what symptoms of MS?
○ Cognitive impairment
○ Fatigue
○ Spasticity
○ Tremor
○ Pseudobulbar affect

spasticity

Which of the following medication can help JP walking? (in MS)

Ampyra (dalfampridine)

Patientcomestoyourpharmacycomplainingofchills,fever,HAandflu-likesymptoms.Shestatesthatshe
has recently started a new medication for MS but she can’t remember the name of it. She tells you that it is
an injection that she takes every other day. Which of the following is she most likely taking?
○ Betaseron
○ Copaxone
○ Tysabri
○ Gilenya
○ Mitoxantrone

Betaseron {Interferons cause flu-like symptoms}

Which patient is most appropriate to respond well to ASA 81mg EC for secondary stroke prophylaxis?

66 year old male with hypertension, dyslipidemia, and ED
○ 56 year old with DM and HTN
○ 46 year old with DM, tobacco use, HTN and dyslipidemia
○ 85 year old with severe acid reflux and uses antacids and high doses of PPI

66 year old male with hypertension, dyslipidemia, and ED

48 year old patient with long term IDDM, dyslipidemia, atrial fibrillation and is experiencing abrupt onset
hemiparesis. Recovered with no deficit. Imaging studies of the brain did report. Doppler studied showed
carotid. At this point, the best option to prevent recurrence would be?
○ Aspirin 325mg
○ Clopidogrel
○ Coumadin
○ Atorvastatin
○ Dipyridamole IR ATC plus Aspirin 81mg

○ Coumadin {Always use anticoag for afib}

76 year old who had a middle cerebral artery infarct on the left side 5 years ago and was previously going to
the VA for his Aggrenox but not it is unavailable through the VA anymore. He is taking Atorvastatin 80mg QD and has dysrhythmias which is treated with amlodipine. He also take omeprazole daily. What might be a reasonable substitute for this patient?
○ Aspirin 325 mg
○ Apixaban
○ Prasagrel
○ Clopidogrel

Aspirin 325 mg {ASA working for patient, need to increase dose from whats in Aggrenox
because your missing the dipyridamole}

What are the medications that can mimic a stroke?

○ Lithium
○ Phenytoin
○ Salicylates
○ TCAs
○ Carbamazepine

○ Lithium
○ Phenytoin
○ Carbamazepine

45 year old female is en route to your hospital via ambulance. She has a subarachnoid
hemorrhage. What of the following are clinical findings of subarachnoid hemorrhage? Choose all that
apply.
○ Sudden onset headache
○ Vomiting
○ Sudden change in mental status
○ Neck stiffness

all of them

A 35 year old with an astrocytoma recently started radiation and is on dexamethasone. Comes to pharmacy and pupils are asymmetrical and has vomitus on his shirt.

○ He may be having a hemorrhagic stroke, he should go to the ED
○ Ensure that he is using a PPI with dexamethasone

60 year old female with a 2 year history of an ependymoma. Following a course of radiation she is
maintained on a combination of temozolomide and thalidomide. She is widowed and cared for daughter and her daughter’s husband. Her daughter has a small child. her daughter is coming to pick up her medications. What is the best course of action? Choose all that apply.

○ Remind the daughter not handle her medication
○ Suggest that that the child have limited time spent with grandmother
○ Tell daughter to use continuous backup contraceptive for at least 6 months if she has
already handled the medication
○ Call MD, there is an interaction between thalidomide and temozolomide
○ Tell her to take the medication night

○ Remind the daughter not handle her medication
○ Tell daughter to use continuous backup contraceptive for at least 6 months if she has
already handled the medication
○ Tell her to take the medication night {Causes drowsiness}

What drugs interact with oral contraceptives?
a. Topiramate
b. Levetiracetam
c. Gabapentin
d. Carbamazepine
e. Phenobarbital

a. Topiramate
d. Carbamazepine
e. Phenobarbital

Which of the following is NOT a potential drug target in treating Alzheimer’s Disease?

increase gamma secretase

All of the following are SEs of memantine except:

a. dizziness
b. confusion
c. diarrhea
d. constipation
e. HA

C. diarrhea

Methylphenidate ER in the ,morning but unable to focus after school what do you recommend?

add methylphenidate 4mg in the afternoon

which helps with depression and neuropathic pain?
a. amitriptyline
b. nortriptyline
c. duloxetine
d. venlafaxine
e. gabapentin

gabapentin

which MS drug is po therapy?
a. teriflunamide
b. rebif
c. natalizumab
d. mitaxontrone
e. glatiramer acetate

a. teriflunamide

Peter is a classmate, and you are attending the same party. Peter’s intoxication became much draw a mask around his eyes worse when he started
drinking shots of Vodka about an hour ago. What would be your best course of action? Choose one.

A: Using a black marker,
B: Put Peter to bed so that he does not drink anymore C: Begin to serve Peter black coffee
D: Stay with Peter to be sure he remains conscious and does not aspirate vomitus. If he becomes more alert over the next 3 hours and stops vomiting he can be put to bed. If he loses consciousness and cannot be aroused easily call 911
E: Call 911 now

D: Stay with Peter to be sure he remains conscious and does not aspirate vomitus. If he becomes more alert over the next 3 hours and stops vomiting he can be put to bed. If he loses consciousness and cannot be aroused easily call 911

The effects produced by ethanol in the Central Nervous System include (Choose all that apply).

A: Ethanol facilitates GABAnergic transmission, GABA is an inhibitory neurotransmitter
B: Ethanol blocks glutamate transmission, Glutamate is an excitatory neurotransmitter
C: Ethanol results in the release of Dopamine in the nucleus accumbens
D: Ethanol binds at endocannabinoid receptors
E: Ethanol activates the opiate peptide system

A 140 lb. man and a 140 lb. women each consume 26 grams of ethanol over a 60-minute period. Each has eaten 6 chicken wings and 1 slice
concentrations for the following reasons. Choose all that apply.
A: Women have less efficient pre-hepatic alcohol dehydrogenase thus there will be greater bioavailability of the alcohol
B: Men have higher testosterone concentrations, which stimulates the bio conversion of ethanol to acetaldehyde
C: Ethanol distributes largely to total body water and lean mass thus women tend to have a smaller volume of distribution/kg
D: Women have greater surface area for absorption in the duodenum, facilitating ethanol’s rate of absorption E: In men, the apparent km and apparent vmax of ethanol are not as close as they are in women
F: Metabolism of ethanol by the CYPZE1 enzyme is greater in men

A: Women have less efficient pre-hepatic alcohol dehydrogenase thus there will be greater bioavailability of the alcohol
C: Ethanol distributes largely to total body water and lean mass thus women tend to have a smaller volume of distribution/kg

Which of the following agents has been associated with drug reaction with eosinophilia and systemic symptoms (DRESS):
A: Ziprasidone (Geodon)
B: Lurasidone (Latuda)
C: Risperidone (Risperdal)
D: Olanzapine (Zyprexa)

A: Ziprasidone
D: Olanzapine

AA is 23 year old obese male patient who is seen at your outpatient clinic for what is newly diagnosed as his first episode of schizophrenia which requires treatment. The psychiatry resident contacts you and asks you which SGAs listed below which are covered by the patient’s insurance, would be the best to initiate for this patient and most appropriate according to the current guidelines.
A: Haloperidol (Haldol)
B: Olanzapine (Zyprexa)
C: Risperidone (Risperdal)
D: Clozapine (Clozaril)

Risperidone

After an initially successful trial of antipsychotic, AA arrives to the acute inpatient emergency department (ED) in a state of extreme agitation. He is aggressive, threatening harm to staff and refuses medication. He is given two intramuscular doses of haloperidol 5mg over the course of his time in the ED with haloperidol 5mg twice daily by mouth, scheduled for continued psychiatric control post discharge. This regimen provides relief from his aggression and psychiatric exacerbation, however results in extreme jaw stiffness. Outside of the jaw stiffness, the patient has no additional symptoms to guide the next treatment intervention. Which movement disorder has AA most likely developed?

A: Akathisia
B: Tardive dyskinesia
C: Neuroleptic Malignant Syndrome
D: Acute dystonic reaction

D: acute dystonic reaction

Which of the following is/are true regarding clozapine therapy? Please select all that apply (SATA):

A: The patient’s ANC should be monitored every month when starting therapy
B: Can result in QTc prolongation
C: ANC values should be submitted to the REMS program
D: It is considered the gold standard and recommended for treatment refractory illness

B: can result in QTc prolongation
C: ANC values should be submitted to the REMS program
D: it is considered the gold standard and recommended for tx refractory illness

How would you describe the class related BBW that is associated with the use of antipsychotic agents (APS)?
A: Avoid use of APS in patients that may be suicidal
B: Avoid use of APS in patients younger than 24 years of age
C: Avoid use of APS in patients with dementia related psychosis
D: Avoid use of APS in patients taking opiate pain relievers

C: avoid use of APS in pts with dementia related psychosis

Despite your most excellent recommendation, the prescriber makes no changes to AA’s regimen (of haloperidol (Haldol) 5mg bid) and discharges him with ibuprofen for his jaw pain. A few weeks later, the patient returns to the ED after transport by ambulance. The paramedics note that he was found on the side of the road, seemingly dehydrated, with extreme muscular rigidity and altered mental status. Labs drawn in ER indicate elevated CPK and elevated body temperature (100 F). What is the likely cause of his current physiologic condition paired with the most appropriate medication related problem?

A: Dystonic reaction: due to medication non-adherence
B: Serotonin syndrome: due possibly to patient’s use of OTC diphenhydramine
C: Neuroleptic malignant syndrome: due to use of high potency antipsychotics when he was dehydrated
D: Physiologic manifestation of psychiatric illness: medications are not to blame

C: Neuroleptic malignant syndrome: due to use of high potency antipsychotics when he was dehydrated

Pete is a developmentally disabled 40-year-old patient who resides in a skilled nursing facility. His epilepsy has been treated with Phenytoin for 20 years with only 2-3 seizures per year. Because he is developing significant dental and gingival problems the decision is made to have his Anticonvulsant changed to Lamotrigine. You’re the pharmacist responsible for this facility. In speaking with the staff responsible for patient care you should: (Choose all that apply)

A: Question the need for Anticonvulsant change. PT has been stable on Phenytoin is not commonly associated with dental problems.
B: Instructed the staff to be vigilant of any cognitive decline as Lamotrigine initiation is commonly very sedating.
C: Be vigilant to examine P for any new rash every day for a month, then at least once per week after that as serious dermatologic conditions can be caused by Lamotrigine.
D: Instruct the staff the Lamotrigine requires a slow titration, so a gradual and simultaneous tapering of Phenytoin and titration of Lamotrigine will be necessary.
E: The staff should be vigilant and take adequate precautions with Pete because there is often a transient increase in seizure frequency during the tapering/titration.

C: Be vigilant to examine P for any new rash every day for a month, then at least once per week after that as serious dermatologic conditions can be caused by Lamotrigine.
D: Instruct the staff the Lamotrigine requires a slow titration, so a gradual and simultaneous tapering of Phenytoin and titration of Lamotrigine will be necessary.
E: The staff should be vigilant and take adequate precautions with Pete because there is often a transient increase in seizure frequency during the tapering/titration.

George is a 60-year-old patient with a history of right middle cerebral artery infarction 5 years ago.2 years ago he experienced 2 generalized tonic-clonic seizures secondary to fibrotic changes in the
seizures have been well controlled on Levetiracetam 1000 mg 3 times daily.He also has a medical history significant for hypertension, degenerative joint disease, and dyslipidemia treated with Lisinopril
Atorvastatin 40 mg at bedtime.Today he presents the hospital complaining of shortness of breath, fatigue, generalized weakness, nauseousness, dystaxic gait and confusion.His wife states that 5 days ago he completed his first marathon and has been taking Ibuprofen 800 mg every 4 hours for 5 days.His comprehensive metabolic profile showed a creatinine clearance of 40 mils per minute. Which of the following could apply? (Choose all that apply).
A: Georges Ibuprofen needs to be stopped immediately.
B: His Levetiracetam dose needs to be increased to 1250 mg 3 times daily as his symptoms may represent partial seizure activity.
C: His Levetiracetam be stopped and replaced with Lamotrigine 100 mg twice daily.
D: His Levetiracetam dose should be lowered to 250 mg twice daily.
E: Valproic Acid 250 mg 3 times daily should be added to his Levetiracetam.

A: Georges Ibuprofen needs to be stopped immediately.
D: His Levetiracetam dose should be lowered to 250 mg twice daily.

Mark is a 36-year-old patient known to you for 5 years. He has a medical history significant for epilepsy diagnosed when he was 10 years old. He typically has 1-3 generalized
significant for hypertension, dyslipidemia, and migraine. Mark’s current medications include: Topiramate 100 mg 3 times daily,Atorvastatin 40 mg at bedtime,Lisinopril 20 mg daily,Sumatriptan dose unspecified as needed for migraine. While waiting for his prescription to be refilled Mark loses consciousness, falls to the floor and after 30 seconds begins convulsing. You should: (Choose all that apply).
A: Go to his side and record the time of onset of seizure
B: Move him to an area clear of furniture and clutter where he is less likely injured himself
C: Turn him onto his back
D: Rinse blood/marks mouth with water if he bites his tongue
E: Stay with marked until he not only has stopped seizing but until he is fully alert or until his cares taken over by a EMS

A: Go to his side and record the time of onset of seizure
B: Move him to an area clear of furniture and clutter where he is less likely injured himself
E: Stay with marked until he not only has stopped seizing but until he is fully alert or until his cares taken over by a EMS

Two weeks later, Mark, the same patient, complains to of bilateral paresthesias in his distal upper extremities. This is a new symptom and has had an insidious onset and is persistent. He reports no
finding difficulties. Since his recent seizures Topiramate was increased to 200 mg in the morning and 200 mg in the evening. Lisinopril dose was increased to 40 mg daily and he is started taking Famotidine 20 mg daily for gastroesophageal reflux.

A: Marks mild expressive aphasia is likely due to to the central nervous system actions of Lisinopril which should be discontinued.
B: Marks mild expressive aphasia and bilateral still paresthesias could be stroke symptoms he should to go to the emergency department
C: Marks expressive aphasia and bilateral distal paresthesias are likely due to an increased dose of Topiramate, he should assure him that this will subside over the next few weeks.
D: Marks mild expressive aphasia and bilateral distal paresthesias are due to a drug drug interaction between Topiramate and Famotidine. He should call his neurologist and make him aware of this interaction. E: None of these choices are likely

C: Marks expressive aphasia and bilateral distal paresthesias are likely due to an increased dose of Topiramate, he should assure him that this will subside over the next few weeks

George is a 17 y/o with new onset of seizures. He was started on on carbamazepine 500 mg. TID 8 weeks ago and has no new seizures. He returns for a refill and tells you that while he is no longer feeling drowsy over the carbamazepine he did have 2 seizures last week. He does not want to tell his neurologist because he does not want to have to start a new anticonvulsant. Which of the following could apply. (Choose all that apply).

A: Assure George that have a couple of seizures is no big deal and that he should just continue to take carbamazepine 500 mg TID
B: Assure George that it is not uncommon for the concentrations of carbamazepine in his blood to fall after 4 – 6 weeks. He should get his carbamazepine levels checked and he may only need an increase in his current dose. You should
have this discussion with Georges neurologist
C: Worsening seizures frequency may indicate a serious anemia that can be associated with carbamazepine treatment and he should go to the Emergency Department
D: Worsening seizure frequency can indicate an electrolyte imbalance that can be associated with Carbamazepine use. George should see his neurologist as soon as possible, he should contact his neurologist office and advised him of Georges potential situation
E: Question George regarding compliance with his Carbamazepine 500 mg 3 times a day in light of his comments with regard to drowsiness which may have led him to noncompliance

B: Assure George that it is not uncommon for the concentrations of carbamazepine in his blood to fall after 4 – 6 weeks. He should get his carbamazepine levels checked and he may only need an increase in his current dose. You should
have this discussion with Georges neurologist
D: Worsening seizure frequency can indicate an electrolyte imbalance that can be associated with Carbamazepine use. George should see his neurologist as soon as possible, he should contact his neurologist office and advised him of Georges potential situation
E: Question George regarding compliance with his Carbamazepine 500 mg 3 times a day in light of his comments with regard to drowsiness which may have led him to noncompliance

Which are important points to make to a patient with epilepsy treated with an AED who asks about breast feeding? Choose all that apply.
A: Maternal uncontrolled seizures pose more of a risk to the new born than exposure to most AED in breast milk
B: If the patient was taking the same AED throughout her pregnancy her child has already been exposed to that AED at least to the same degree without problems
C: Zonisamide is considered the safest AED for breast feeding mothers
D: Newer agents such as topiramate seem safer than older agents but this is based on much less data/experience
E: Patients should be warned to monitor for sleepiness of the child after feeding

A: Maternal uncontrolled seizures pose more of a risk to the new born than exposure to most AED in breast milk
B: If the patient was taking the same AED throughout her pregnancy her child has already been exposed to that AED at least to the same degree without problems
D: Newer agents such as topiramate seem safer than older agents but this is based on much less data/experience

Which scenario correctly matches this description? A patient has used 1-3 lines of cocaine throughout the night on multipole different occasions multiple times. More recently they have been brought use. Today the patient is brought to the ER after having a seizure in the club. He is surprised because he has cut back on the amount he used, only using 1 line.
A: Sensitization
B: Tolerance
C: Withdrawal
D: Physical Dependence

A: sensitization

Which drug is BEST paired with its characteristics?

A: Krokodil – analogs of a naturally occurring plant that has amphetamine-like stimulatory effects
B: Bath salts / Cathinones – analogs of naturally chemicals found in marijuana sold as “herbal products” C: Synthetic Cannabinoids – a homemade potent short-acting opioid often highly contaminated and made with caustic chemicals and solvents
D: Kratom – a legal plant product that has stimulant effects at lower doses and opiate effects at higher doses
E: None are correctly paired

D: Kratom – a legal plant product that has stimulant effects at lower doses and opiate effects at higher doses

CC is a 30-year old obese male with a history of depression and some previous episodes of mania which included euphoria, grandiosity and impulsivity. He recently arrived to the emergency department while experiencing an acute depressive episode. The attending prescriber is considering the use of a benzodiazepine (BZD) in addition to a second generation antipsychotic (SGA) for future episodes and manic symptoms. What would you advise CC’s prescriber of the appropriate role of BZD in the treatment of bipolar disoder? Please select all that apply (SATA):

A: Use lowest effective BZD dose
B: Short term augmentation with BZD and then discontinue
C: Use scheduled doses of BZD only
D: Absolute avoidance of BZD is essential

A: Use lowest effective BZD dose
B: Short term augmentation with BZD and then discontinue

CC is a 30-year old obese male with a history of depression and some previous episodes of mania which included euphoria, grandiosity and impulsivity. He recently arrived to the emergency department while experiencing an acute depressive episode of his bipolar disorder. The attending prescriber is considering the use of a second generation antipsychotic (SGA) for the management of future episodes. Which of the following SGAs are FDA approved for bipolar disorder and has evidence to support efficacy in treating depressive episodes? Please select all that apply (SATA):
A: Aripiprazole (Abilify)
B: Risperidone (Risperdal)
C: Quetiapine (Seroquel)
D: Lurasidone (Latuda)

C: quetiapine (Risperdal)
D: Lurasidone (Latuda)

In addition to bipolar disorder, which of the following psychiatric conditions are appropriate FDA approved uses for the antipsychotic quetiapine (Seroquel)? Please select all that apply (SATA)
A: Depression augmentation
B: Social Anxiety Disorder (SAD)
C: Insomnia
D: Psychosis

A: depression augmentation
d: Psychosis

KB is a 70 year old female patient who was diagnosed in the past with generalized anxiety disorder (GAD) and has recently described a recurrence of anxiety symptoms. Her psychiatrist started her on paroxetine (Paxil) 20mg 2 weeks ago; however she is finding her “physical” symptoms of anxiety too overwhelming to wait for the SSRI to start working. She has been self-medicating with OTC antacids for stomach symptoms and Tylenol PM (acetaminophen with diphenhydramine) for insomnia for the last few weeks. Her complete medication list includes the following: Paroxetine (Paxil) 20mg daily Maalox (aluminum/magnesium) 1 tablespoonful TID PRN Acetaminophen with diphenhydramine (Tylenol PM) HS PRN Ibuprofen (Motrin) 200mg TID PRN for arthritic pain KB’s psychiatrist decides to initiate clonazepam (Klonopin) 0.5mg three times daily as needed for her anxiety and at the same time instructs the patient to discontinue her acetaminophen with diphenhydramine (Tylenol PM). KB arrives to your clinic 2 weeks later for a psychiatric follow up. During her appointment, she reports finding blood in her stool. If this bleeding were confirmed to be a result of an adverse drug event, what drug would most likely contributed to this adverse effect?

A: clonazepam (Klonopin)
B: acetaminophen (Tylenol)
C: paroxetine (Paxil)
D: diphenhydramine (Benadryl)

C: paroxetine

Z is a 66 year old female patient who was diagnosed in the past with generalized anxiety disorder (GAD) and has recently described a recurrence of anxiety symptoms. Her psychiatrist started her on paroxetine (Paxil) 20mg 2 weeks ago; however she is finding her “physical” symptoms of anxiety too overwhelming to wait for the SSRI to start working. She has been self-medicating with OTC antacids for stomach symptoms and Tylenol PM (acetaminophen with diphenhydramine) for insomnia for the last few weeks. Her complete medication list includes the following: Paroxetine (Paxil) 20mg daily Maalox (aluminum/magnesium) 1 tablespoonful TID PRN Acetaminophen with diphenhydramine (Tylenol PM) HS PRN Ibuprofen (Motrin) 200mg TID PRN for arthritic pain ZZ’s psychiatrist decides to initiate clonazepam (Klonopin) 0.5mg three times daily as needed for her anxiety and at the same time instructs the patient to discontinue her acetaminophen with diphenhydramine (Tylenol PM). ZZ is very concerned about her recent bleeding episode and she would like to know what other adverse effects she is at high risk of experiencing relative to the medication she is currently taking. Which of the following drugs and appropriately matched (commonly associated) adverse effect would you warn her about? Please select all that apply (SATA):

A: Clonazepam: increased risk of falls and fractures
B: Diphenhydramine: increased risk of thrombocytopenia C: Acetaminophen: increased risk of renal failure
D: Paroxetine: withdrawal symptoms if she forgets to take her daily dose

A: clozapam: increased risk of falls and fractures
D: paroxetine: withdrawal symptoms if she forgets to take her daily dose

mission, MO’s symptoms were determined to be a panic attack. He has a history of panic attacks in the past, but has never taken medication. MO’s physician diagnoses him with panic disorder and would like to initiate medication. Which of the following medications would be appropriate selections as monotherapy for panic disorder? Please select all that apply (SATA):

A: Fluoxetine (Prozac)
B: Venlafaxine (Effexor) XR
C: Sertraline (Zoloft)
D: Temazepam (Restoril)

A: Fluoxetine (Prozac)
B: Venlafaxine (Effexor) XR
C: Sertraline (Zoloft)

PP is a 61-year-old military veteran who was recently diagnosed with post-traumatic stress disorder (PTSD) who denies any history of substance use/abuse. His current comorbid medical conditions include benign prostatic hypertrophy, insomnia and glaucoma. He has been taking sertraline (Zoloft)100mg daily (the MDD is 200mg) for 4 weeks and describes a reduction in symptoms however is still expressing distress over memories of witnessing deaths of fellow servicemen during combat. What would you recommend for PP at this time?

A: Add clonazepam (Klonopin) 1mg three times daily PRN intrusive thoughts
B: Add phenelzine (Nardil) 15mg at bedtime
C: Add quetiapine (Seroquel) 25mg daily
D: Increase sertraline to 150mg

D: increase sertraline to 150 mg

PP’s MD contacts you a few weeks later, thanking you for your recommendation and describes an improvement in PP’s function and core symptomatology. Now, the MD would like to prescribe another medication to help PP with some nightmares and flashbacks that continue to be a problem every few nights. What agent do you recommend?

A: Metoprolol Succinate (Toprol XL)
B: Prazosin (Minipress)
C: Clonazepam (Klonopin)
D: Estazolam (Prosom)

Prazosin (minipress)

Which of the following serotonin norepinephrine reuptake inhibitors (SNRIs) is most the appropriate recommendation to treat major depressive disorder (MDD) and co-occuring generalized anxiety disorder (GAD) in a 34 year old female patient without any additional medical comorbidities?

A: Paroxetine (Paxil)
B: Venlafaxine (Effexor)
C: Desvenlavaxine (Pristiq)
D: Escitalopram

B: venlafaxine (Effexor)

A 23-year-old patient has recently been diagnosed with a first episode of MDD by her primary provider. The patient has been referred for antidepressant medication initiation. Identified target symptoms are depressed mood, anhedonia, insomnia, and impaired concentration. The patient denies suicidal ideation. The patient discusses treatment options with her prescriber noting that her mother did well with sertraline (Zoloft) and requests this medication. The prescriber agrees and initiates sertraline (Zoloft) 50mg once daily in the morning. After 14 days, the patient reports decreased jitteriness and anxiety, and improved sleep since she started taking the medication. She expresses concerns over the initial jitteriness she experienced and hopes that will not happen again. What is the most appropriate recommendation to manage this patient?
A. Increase dose
B. Change to another SSRI
C. Add aripiprazole (Abilify) 5mg
D: Encourage continues reporting of side effects

D: Encourage continues reporting of side effects

A. The BBW for ADs is not applicable; it only applies to patients with dementia related psychosis
B. The BBW for ADs is not applicable; this patient does not describe suicidal ideation
C. The BBW for ADs is applicable; counsel patient to notify prescriber if a change of mood occurs
D. The BBW for ADs is applicable; this patient is at risk of QTc prolongation and Torsades (TdP)

C. The BBW for ADs is applicable; counsel patient to notify prescriber if a change of mood occurs

37-year-old male patient recently diagnosed with a 2nd episode of MDD by their primary provider and has been referred for antidepressant therapy. The patient identifies target symptoms as depressed mood, decreased appetite and insomnia. The patient denies suicidal ideation. He previously achieved remission while on paroxetine, however he remembers feeling drowsy during the day when taking the medication in the morning. He requests a different type of medication this time. His past medical history includes seizures and psychiatric history for depression (sister). His current medications include: Divalproex (Depakote ER) 1000mg daily, lamotrigine (Lamictal) 100mg daily Based on the patient’s history and presentation, which SNRI antidepressant would be the most appropriate pharmacotherapy for this patient?

A. Nefazadone (Serzone)
B. Bupropion (Wellbutrin)
C. Venlafaxine (Effexor)
D. Phenelzine (Parnate)

C. Venlafaxine

What are potential adverse events of selective serotonin norepinephrine reuptake inhibitors (SNRIs)? Please select all that apply (SATA)

A. Abnormal bleeding
B. Increased blood pressure
C. Mania if used as monotherapy in patients with bipolar disorder
D. Hypernatremia

A. Abnormal bleeding
B. Increased blood pressure
C. Mania if used as monotherapy in patients with bipolar disorder

Mrs. G is a 54-year-old woman who presents to the movement disorder clinic complaining of a one-year history of “stiffness” in her right arm and difficulty with fine motor tasks. Her husband has also noticed that she has begun walking more slowly and with a slightly stopped, shuffling gait. Upon physical exam and further supportive findings, she is diagnosed with mild idiopathic Parkinson’s disease. She will initiate pharmacologic treatment. Mrs. G is in good overall health, has no significant past medical history and is not currently taking any medications aside from a multivitamin. Which among the following choices are appropriate monotherapies for initial treatment of Mr. G’s Parkinson’s Disease? Select all that apply.

A: Carbidopa/Levodopa (Sinemet) 25/100 mg tablets, 1 tablet TID.
B: Pimavanserin (Nuplazid) 2x17 mg tablets QD.
C: Apomorphine (Apokyn) 0.2 ml, titrated to effect and given “as needed” for “off” episodes.
D: Ropinirole (Requip) 0.25 mg TID, to be titrated to effect. E: Entacapone (Comtan) 200 mg TID

A: Carbidopa/Levodopa (Sinemet) 25/100 mg tablets, 1 tablet TID.
D: Ropinirole (Requip) 0.25 mg TID, to be titrated to effect. E: Entacapone (Comtan) 200 mg TID

Mr. Z’s doctor accepted your recommendation, and Mr. Z and his daughter report immediate improvement in his symptoms of hallucinations. However, 1 year later they return to the office reporting that the hallucinations have returned. Mr. Z frequently sees strangers in his house, and has had several urine accidents during the nighttime due to being afraid to leave his bed to use the bathroom. Mr. Z’s neurologist does not wish to reduce the dose of any of his PD medications at this time, as his motor function has continued to decline. Mr. Z’s neurologist asks for your recommendation about an appropriate antipsychotic medication for Mr. Z. Which is the LEAST appropriate recommendation for Mr. Z?

A: Pimavanserin (Nuplazid) 2x17 mg tablets QD. B: Clozapine 12.5 mg QHS.
C: Quetiapine (Seroquel) 12.5 mg QHS.
D: Haloperidol 2 mg QHS.

D: Haloperidol 2 mg QHS

Mr. Z is an 85-year-old man with 15-year history of PD. He presents to clinic with his caregiver, his daughter. Mr. Z’s daughter reports that he has been experiencing a 1-year history of visual and auditory hallucinations; frequently, he will see strangers in the house or in his yard, when in fact no one is there. The hallucinations are frightening to him and sometimes keep him from leaving his bedroom during the day. His current medications include: Sinemet 25/100 mg tablets, 1.5 tablets qid, rasagiline 1 mg PO QD, lisinopril 20 mg qd, benztropine 1 mg BID and tamsulosin 0.4 mg QD. After ruling out medical causes of Mr. Z’s symptoms (such as infection or electrolyte imbalance), Mr. Z’s neurologist asks you for your recommendation. Which of the following is the MOST appropriate recommendation at this time?

A: Attempt to switch rasagiline 1 mg po QD to selegeline ODT (Zelapar) 1.25 mg QD.
B: Initiate pimavanserin (Nuplazid) 2x17 mg tablets QD.
C: Attempt to reduce Sinemet dosing frequency to 1.5 tablets TID.
D: Attempt to taper and discontinue benztropine 1 mg BID.

D: attempt to taper and d/c benztropine 1 mg BID

Which of the following is TRUE regarding rasagiline (Azilect?) Select all that apply.

A: Rasagiline works by inhibiting catechol o-methyl transferase (COMT), thereby preventing breakdown of l-dopa and prolonging its effect.
B: Rasagiline may have potential disease-modifying effects in treatment of PD based on large clinical trials. C: Rasagiline should not be used as a monotherapy in treating Parkinson’s disease.
D: When used in the correct therapeutic dosing range for Parkinson’s Disease, rasagiline selectively inhibits the monoamine oxidase B enzyme.

B: Rasagiline may have potential disease-modifying effects in treatment of PD based on large clinical trials.

D: When used in the correct therapeutic dosing range for Parkinson’s Disease, rasagiline selectively inhibits the monoamine oxidase B enzyme.

r. F is a 64-year-old man diagnosed with PD 3 years ago. He currently takes Sinemet 25/100 mg tablets TID. He presents to the clinic complaining that although the medication seemed to be working well at first, he has lately been experiencing “wearing-off” of his medication about an hour before it is time to take his next dose, with particularly bothersome symptoms of slowness and “stiffness” which prevent him from doing his exercises. He is on no other concomitant medications and has no comorbid medical conditions. Which of the following is THE MOST appropriate recommendation regarding Mr. F’s medication regimen at this time?

A: Recommend increasing Mr. F’s Sinemet 25/100 mg dosing frequency from TID to QID.
B: Counsel Mr. F to always take his Sinemet with a full, protein-rich meal in order to increase absorption of the medication. C: Recommend Mr. F increase his Sinemet dose to 25/100 mg, 2 tablets TID.
D: Recommend addition of benztropine 1 mg BID for better symptom control.

A: Recommend increasing Mr. F’s Sinemet 25/100 mg dosing frequency from TID to QID.

Which of the following is TRUE concerning the etiology and pathophysiology of Parkinson’s disease (PD)? Select all that apply.

A: Urban life and cigarette smoking are 2 known factors which increase the risk of developing PD.
B: PD is characterized by a state of dopamine deficiency in the brain, caused by loss of dopaminergic cells in the substantia nigra and basal ganglia. C: Decreased acetylcholine signaling is thought to be responsible for the motor symptoms of PD.
D: The accumulation of beta-amyloid plaques and neurofibrillary tangles in the brain is a pathophysiologic hallmark of PD.
E: The accumulation of Lewy bodies (clumps of alpha-synuclein protein) in the substantia nigra and other areas of the brain is a pathophysiologic hallmark of PD.

B: PD is characterized by a state of dopamine deficiency in the brain, caused by loss of dopaminergic cells in the substantia nigra and basal ganglia.

E: The accumulation of Lewy bodies (clumps of alpha-synuclein protein) in the substantia nigra and other areas of the brain is a pathophysiologic hallmark of PD.

JM is a 74 year old male who was diagnosed with bipolar disorder in his mid-20s and who now developed swallowing difficulties due to progressively worsening dementia. JM’s psychiatrist would like to order a mood stabilizing long acting antipsychotic (LAI) injection that can appropriately manage his bipolar disorder. Which of the following second generation antipsychotics (SGAs) are available as LAI? Please select all that apply (SATA):

A: Aripiprazole (Abilify)
B: Risperidone (Risperdal)
C: Quetiapine (Seroquel)
D: Lurasidone (Latuda)

A: Aripiprazole (Abilify)
B: Risperidone (Risperdal)

WD is a 68 year old male currently hospitalized for mania. Because WD had previously exhibited depressive episodes of bipolar disorder (BP-I), his psychiatrist is considering ordering an antidepressant to WD’s regimen upon discharge. What is the most appropriate way to use antidepressant agents in patients with bipolar disorder?

A: Only use antidepressants for bipolar mania
B: Only use dual action antidepressant agents (SNRIs, TCAs)
C: Only use when prescribed along with a mood stabilizer
D: Only use as monotherapy if they are FDA approved for use

C: Only use when prescribed along with a mood stabilizer

WD is a 68 year old male currently hospitalized for mania. His treatment team psychiatrist would like to hear about additional antipsychotic options to treat bipolar disorder. Which of the following second generation antipsychotics (SGAs) is approved for treatment of bipolar disorder and is least likely to worsen potential metabolic cardiovascular risks in this patient?
A: Quetiapine (Seroquel)
B: Aripiprazole (Abilify)
C: Clozapine (Clozaril)
D: Thioridazine (Mellaril)

B: aripiprazole (Abilify)

WD is a 68 year old male currently hospitalized for an episode of mania. His daughter attends a treatment planning team for her dad and she weighs in on her concerns about his care. She mentions she has heard that some antipsychotics have been associated with gynecomastia and she wants to avoid having her dad experience that side effect. Which of the following second generation antipsychotic agents (SGA) is approved for use in bipolar disorder and is also MOST likely to cause gynecomastia in males?

A: Lurasidone (Latuda)
B: Iloperidone (Fanapt)
C: Risperidone (Risperdal)
D: Vilazodone (Viibryd)

C: risperidone

BW is a 32-year-old white male patient who arrives to the emergency department today in distress and was triaged to address what was determined to be an episode of bipolar depression. BW reports he has experienced feelings of depression in the past, however said he could “ignore” his symptoms before but knows he needs someone else’s help today. What pharmacotherapeutic combination represents an optimal intervention for a patient experiencing an acute episode of bipolar depression in a patient diagnosed with BP-II disorder? Please select all that apply (SATA):

A: quetiapine (Seroquel) with divalproex (Depakote)
B: olanzapine (Zyprexa) with fluoxetine (Prozac)
C: paliperidone (Invega) with gabapentin (Neurontin) D: ziprasidone (Geodon) with aripiprazole (Abilify)

A: quetiapine (Seroquel) with divalproex (Depakote)
B: olanzapine (Zyprexa) with fluoxetine (Prozac)

A 53-year-old female patient recently diagnosed with a 1st episode of MDD by their primary provider has been referred for antidepressant therapy. The patient reports a loss of interest in activities she typically enjoys, insomnia, and difficulty concentrating at work each day. Past Medical History: Type 2 diabetes with diabetic peripheral neuropathic pain Current medications: Metformin 1000mg twice daily, vitamin B12 500 mcg intranasally in one nostril once weekly, insulin glargine 60 units every evening, insulin lispro 18 units 15 minutes before meals, sliding scale insulin, atorvastatin 40 mg daily, lisinopril 40 mg daily Substance use: Caffeine: Denies Tobacco: Denies Alcohol: Denies Illicit: Denies Vital signs: Pulse: 78 beats per minute Blood pressure: 143/82 mmHg Height: 75 inches Weight: 120 kg Given the patient’s diabetic neuropathy and depression, which of the following serotonin norepinephrine reuptake inhibitor (SNRI) antidepressant medication is FDA approved for both neuropathic pain and depression?

A. Duloxetine (Cymbalta)
B. Phenelzine (Parnate)
C. Fluvoxamine (Luvox)
D. Fluoxetine (Prozac)

A: Duloxetine

Which of the following antidepressants is most correctly paired with the adverse effect most likely associated with its use?
A. Citalopram (Celexa): Avoid in patients with seizure disorder
B. Bupropion (Wellbutrin) : Avoid in patients with QTc prolongation
C. Paxil (paroxetine): Avoid in patients who are pregnant
D. Sertaline (Zoloft): Avoid in patients who smoke

C. Paxil (paroxetine): Avoid in patients who are pregnant

A 23-year-old patient has recently been diagnosed with a first episode of MDD by her primary provider. The patient has been referred for antidepressant medication initiation. Identified target symptoms are depressed mood, anhedonia, insomnia, and impaired concentration. The patient denies suicidal ideation. The patient discusses treatment options with her prescriber noting that her mother did well with sertraline and requests this medication. The prescriber agrees and initiates sertraline daily. After 14 weeks of taking 200mg daily (the maximum daily dose), the patient reports only a small, but noticeable, improvement in her mood since she started taking the medication, but has continued to experience difficulty concentrating which is causing trouble at her job. What are all possible and appropriate recommendations to manage this patient? Please select all that apply (SATA)

A. Decrease dose
B.Discontinue the SSRI
C. Add aripiprazole (Abilify) 5mg
D. Encourage continued reporting of side effects and benefits of therapy

C. Add aripiprazole (Abilify) 5mg
D. Encourage continued reporting of side effects

A 23-year-old patient has recently been diagnosed with a first episode of MDD by her primary provider. The patient has been referred for antidepressant medication initiation. Identified target symptoms are depressed mood, anhedonia, insomnia, and impaired concentration. The patient denies suicidal ideation. The patient discusses treatment options with her prescriber noting that her mother did well with sertraline (Zoloft) and requests this medication. The prescriber agrees and initiates sertraline (Zoloft) at the recommended starting dose of 50mg once daily in the morning. After 4 days, the patient reports some jitteriness and increased anxiety since she started taking the medication. What is the most appropriate recommendation to manage this effect?

A. Discontinue antidepressant, she is experiencing a side effect from the SSRI
B. Encourage continued reporting of side effects and benefits of therapy
C. Increase dose, she is experiencing a psychiatric exacerbation
D. Add aripiprazole (Abilify) 5mg as augmentation to sertraline therapy

B. Encourage continued reporting of side effects and benefits of therapy

PP confides in you and shares that that his 22-year-old son was just diagnosed with obsessive compulsive disorder (OCD). PP feels that this may be because his son is always worried about him and how his PTSD symptoms are “destroying his dad’s life”. He wants your opinion about pharmacologic options for him. Which of the following would be the best medication to initiate for his son’s treatment and is FDA approved for monotherapy in OCD? Please select all that apply (SATA):

A: Sertraline (Zoloft) 50mg daily
B: Paroxetine (Paxil) 20mg daily
C: Quetiapine (Seroquel) 100mg daily
D: Lorazepam (Ativan) 1mg daily

A: Sertraline (Zoloft) 50mg daily
B: Paroxetine (Paxil) 20mg daily

JJ is a 37-year-old patient that presents to the ED with severe social anxiety disorder (SAD) that has caused significant impairment. The physician is planning to prescribe an antidepressant, however would also like to initiate a benzodiazepine (BZD) with quick onset for his acute exacerbation of anxiety. Because JJ may have latent hepatitis B infection, the physician would like a BZD that represents the safest option for use in patients with hepatic impairment and that is FDA approved for anxiety. Which of the following BZDs would be most appropriate for use in patients with anxiety and impaired hepatic function?

A: Diazepam (Valium)
B: Temazepam (Restoril)
C: Lorazepam (Ativan)
D: Oxazepam (Serax)

C: Lorazepam

BDG is a 60 year old male who weighs 350 lbs. that experienced an episode of abrupt onset dystaxia, nausea, diplopia, and upper right extremity paresthesias. He sought medical care and imaging studies of his brain revealed a dissection or thrombosis of the left vertebral artery and infarction in the left lateral medulla. His symptoms slowly resolved leaving him with only a mild dystaxia. He also takes omeprazole for GERD, amlodipine and hydrochlorothiazide for essential hypertension, and atorvastatin for dyslipidemia. He has a history of migraine and a family history for migraine. Based on both outcomes data as well as the specific clinical circumstances of this patient which would be the best for long-term secondary stroke prophylaxis?

A: Aspirin 325 mg daily
B: Plavix 75 mg daily
C: Aggrenox twice daily
D: Ticlopidine
E: Aspirin 81 mg daily

A: aspirin 325 mg daily

Richard is an 81 year old man who was admitted to hospital in September for sudden onset difficulties with gait, balance, double vision, speech difficulties and nausea. Imaging studies of
had been taking aspirin 81 mg daily prior to this stroke. He has some residual speech and balance difficulties. He was discharged on aspirin 325 mg daily. His current medications include : Aspirin 325 mg daily Atorvastatin 80 mg at bedtime piroxicam 10 mg three times daily lisinopril 20 mg daily hydrochlorthiazide 12.5 mg daily. He is in for a refill of all of his medications. Which would be your single best course of action

A: Refill his medications and reinforce that should he have a recurrence symptoms like those in September he needs to call 911 B: Contact his physician because the atorvastatin dose should be no more than 40 mg daily in patients over 55 years old
C: Contact his physician because hydrochlorthiazide can cause dehydration which will increase the risk of recurrent stroke
D: Contact his physcian because piroxicam will severely compromise the antiplatelet effects of aspirin
E: Contact his physcian and ask that he be treated with apixaban rather than aspirin because he had a pontine stroke

D: Contact his physcian because piroxicam will severely compromise the antiplatelet effects of aspirin

Ben is a 60-year-old male with SPMS. He is seen with his wife for a routine follow-up. His wife mentions that he now has uncontrollable episodes of laughing and crying. His neurologist is thinks he may have Pseudobulbar Affect (PBA). Which medication is approved or PBA?

A: Dalframpridine / Ampyra
B: Mirabegron / Myrbetriq
C: Dextromethorphan and Quinidine / Neudexta
D: Modafanil / Provigil

C: Dextromethorphan and Quinidine / Neudexta

Maary has been diagnosed with Primary Progressive Multiple Sclerosis. She has had steady disease progression without clear-cut relapses. Which medication is approved, but has shown the best efficacy for PPMS?

A: Glatiramir Acetate / Copaxone
B: Ocrelizumab / Ocrevus
C: Fingolimod / Gilenya
D: Dimethyl fumarate / Tecfidera

B: Ocrelizumab

A 25-year-old female, has had multiple trips to the ER for severe headaches. These headaches start all of
MRI of the brain and lumbar puncture at first visit were unremarkable. There was no evidence of any subarachnoid hemorrhage or bleeding in the head. She has a past medical history of typical migraine headaches, however, these are more unilateral, throbbing, associated with nausea, light sensitivity. She was recently diagnosed with major depressive disorder, after episode of binge drinking, and started on Citalopram. She has been self-medicating with marijuana, and noticed that it helps her with sleep as well as her anxiety. She is currently in her menstruation cycle, has been taking newly prescribed hormonal Contraceptive but contains higher dose of Estrogen than her previous combination pill. What is the diagnosis, and what medications and or factors in her clinical history can be a contributing factor to her presenting symptoms? Check all that apply.

A: Thunderclap headache from binge drinking.
B: Thuderclap headache from ruptured aneurysm from marijuana use with SSRI
C: Reversible cerebral vasoconstriction syndrome from marijuana, SSRI, high estrogen dose.
D: Reversible cerebral vasoconstriction syndrome from alcohol and marijuana
E: Reversible vasoconstriction syndrome from SSRI, marijuana

D: Reversible cerebral vasoconstriction syndrome from alcohol and marijuana * E: Reversible vasoconstriction syndrome from SSRI, marijuana

A 54-year-old male patient with past medical history of controlled hypertension, diabetes, hyperlipidemia, currently on low-dose Aspirin, experiencing 4-8 migraine headache days per month. He is a nonsmoker, non-obese, and has a non- stressful job working as a school bus driver. He has tried Sumatriptan in the past without significant benefit, but he did have adverse reactions. Which of the following medications below do not have any vascular constriction, and could be a good choice for this patient for acute treatment? (Check all that apply).

A: Ubrelvy (ubrogepant)
B: Nurtec (rimegepant)
C: Reyvow (lasmiditan)
D: Aimovig (Erenemuab)
E: Maxalt (rizatriptan)

A: Ubrelvy (ubrogepant)
B: Nurtec (rimegepant)

Which of the following patient presentations may be a ‘red flag’ while evaluating a patient for headache and warrant further work up. (Check all that apply).

A: 19 y. o. Obese female with migraine without aura, positive for smoker.
B: 31 y. o. female with whose headaches are exacerbated with vasalva.
C: 45 y. o. female that experiences numbness and tingling down the left side of her extremeties, with an increase in frequency of headaches.
D: 35 y. o. cluster headache patient with positive neurological signs such as eyelid droop during acute attack.
E: 50 y. o. male with right temporal pain, and scalp tenderness.

B: 31 y. o. female with whose headaches are exacerbated with vasalva.
C: 45 y. o. female that experiences numbness and tingling down the left side of her extremeties, with an increase in frequency of headaches.
E: 50 y. o. male with right temporal pain, and scalp tenderness.

George is a 50-year-old male with a history of essential hypertension who comes into your pharmacy
wife isn’t sleeping well either. She tells him he is kicking her all night long. For his own benefit, as well as his wife’s, can you recommend an over-the-counter product to help them sleep? Which is your single best course of action?

A: Have him start taking diphenhydramine 50-75 mg at bedtime, a review of his records provides no medical reasons not to, and it will help his sleep. You cannot make recommendations regarding his wife becuase you do not have her records.
B: Have George and his wife start taking diphenhydramine 50-75 mg at bedtime. It is a safe dose, and there are very few contraindications in 45-50-year-olds
C: Suggest he call his primary care physician
D: Have him start taking vitamin B and iron supplements. If the symptoms do not improve, refer him to a sleep medicine provider. Warn him not to use over-the-counter sleep aids
E: Call his primary care provider because metoprolol may be aggravating these symptoms

Have him start taking vitamin B and iron supplements. If the symptoms do not improve, refer him to a sleep medicine provider. Warn him not to use over-the-counter sleep aids

Patients with obstructive sleep apnea should always take their CPAP machine with them if they are hospitalized because untreated obstructive apnea can: Choose one.

A: cause renal artery perfusion and reduction in glomerular filtration rate
B: increase the likelihood of iatrogenic pneumonia, especially in a hospital
C: decrease the hypercapnic and hypoxic drive to breath when patients are treated with narcotics
D: exacerbate preload and aggravate congestive heart failure
E: none of the listed answer choices are true statements

C: decrease the hypercapnic and hypoxic drive to breath when patients are treated with narcotics

A 75-year-old woman comes into your pharmacy asking for something to help her sleep. Despite going to bed at 9:30 PM nightly, she is rearely
She arises each morning feeling unrested. Her social life, while relatively stable during the past year, is disrupted because she is compelled to nap daily between 3 and 4:30 p.m. She is an otherwise well-nourished, hypertensive patient well- controlled with atenolol 50 mg daily. What would you recommend for this patient? Choose one.

A: Diphenhydramine 25 mg at bedtime along with sleep hygiene counseling
B: Suvorexant 1 mg, no more than 30 mg before bed
C: Evaluation for Obstructive Sleep Apnea
D: Triazolam 0.25 mg at bedtime for 2 weeks along with sleep hygiene counseling
E: Sleep hygiene counseling

E: sleep hygiene counseling

: In the 1st year in a long term care facility, a gradual dose reduction (GDR) must be attempted twice in two separate quarters with at least 1 month in between. After the 1st year, how many times per year should a gradual dose reduction be attempted?
A: 1
B: 2
C: 3
D: 4

arry is in a nursing home and has severe Alzherimer’s disease. He has become quite combative with the nursing staff and other residents. It is fears that he will be a danger to others and staff due to his agitation. The staff has employed non-pharmacologic methods, but the agitation remains problematic. You have educated the prescriber, staff and family on the black box warning for antipsychotics but all believe benefit outweighs the risk. They ask you, according to AHRQ, which antipsychotic has the highest antipsychotic efficacy data for dementia agitation AND dementia overall?
A: Aripiprazole
B: Quetiapine
C: Risperidone
D: Olanzapine

Rispeidone

Marilyn is taking Aricept 5 mg QHS. She comes to the pharmacy and tells you she has started to experience very vivid dreams, which are sometimes nightmares that awake her from her sleep. Which is the appropriate counseling point at this time?

A: Offer to call her presciber and recommend a switch to rigastigmine capsules 3 mg BID
B: Advise her to try taking Aricept in the morning
C: Advise her to take Aricept with food
D: Tell her this is not a side effect of Aricept and offer to review the rest of her medications

B: Advise her to try taking Aricept in the morning

True or False: Prior exposure to anticholinergic medications has been shown to cause Dementia.
A: True
B: False

false

Sally saw her neurologist and after an extensive work-up diagnosed her with mild Alzheimer Disease. Her neurologist would like to start her. on an acetlycholinsterase inhibitor. She has heard from a friend whose husband took them that these medications can cause a lot of stomach upset and would like to avoid it if possible? Which of the following acetylcholinesterase inhibitors
A: Rivastingmine capsules
B: Glantamine ER capsules
C: Aricept ODT tablets
D: Memantine tablets

A: Rivastingmine

Norma is a 75 year old woman. She is experiencing some difficulty with her memory. She is taking the following medications: Lisinopril 10mg, Atorvastatin 20 mg, oxybutynin 10 mg. which medications is of the greatest concern for her memory? Choose one.
A: Lisinopril 10 mg
B: Lexapro 10 mg
C: Atorvastatin 20 mg
D: Oxybutynin 10 mg

Oxybutynin 10 mg

Brainscape's Knowledge GenomeTM

Exam 4 and Final Flashcards

Brainscape's Knowledge Genome^TM